Nervous System | Neurological Disorders NCLEX Quiz 51 | Attempts: 2472

1.

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

A.

A cerebral lesion
B.

A temporal lesion
C.

An intact brainstem
D.

Brain death

Correct Answer
C. An intact brainstem

Explanation
Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal. cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III. IV. and VIII is conjugate eye movements toward the side being irrigated. followed by rapid nystagmus to the opposite side. Absent or disconjugate eye movements indicate brainstem damage.

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2.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

A.

Increasing temperature. increasing pulse. increasing respirations. decreasing blood pressure.
B.

Increasing temperature. decreasing pulse. decreasing respirations. increasing blood pressure.
C.

Decreasing temperature. decreasing pulse. increasing respirations. decreasing blood pressure.
D.

Decreasing temperature. increasing pulse. decreasing respirations. increasing blood pressure.

Correct Answer
B. Increasing temperature. decreasing pulse. decreasing respirations. increasing blood pressure.

Explanation
A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

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3.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

A.

A positive Brudzinski’s sign
B.

A negative Kernig’s sign
C.

Absence of nuchal rigidity
D.

A Glascow Coma Scale score of 15

Correct Answer
A. A positive Brudzinski’s sign

Explanation
Signs of meningeal irritation compatible with meningitis include nuchal rigidity. positive Brudzinski’s sign. and positive Kernig’s sign. Brudzinski’s sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest.Option B: Kernig’s sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position.Option C: Nuchal rigidity is characterized by a stiff neck and soreness. which is especially noticeable when the neck is fixed.Option D: A Glasgow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

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4.

A client is arousing from a coma and keeps saying. “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

A.

Tolerate the pain
B.

Decrease the perception of pain
C.

Escape the source of pain
D.

Divert attention from the source of pain.

Correct Answer
C. Escape the source of pain

Explanation
The client’s innate responses to pain are directed initially toward escaping from the source of pain.Options A. B. and D: Variations in individuals’ tolerance and perception of pain are apparent only in conscious clients. and only conscious clients are able to employ distraction to help relieve pain.

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5.

During the acute stage of meningitis. a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

A.

Limiting conversation with the child
B.

Keeping extraneous noise to a minimum
C.

Allowing the child to play in the bathtub
D.

Performing treatments quickly

Correct Answer
B. Keeping extraneous noise to a minimum

Explanation
A child in the acute stage of meningitis is irritable and hypersensitive to loud noise and light. Therefore. extraneous noise should be minimized and bright lights avoided as much as possible.Option A: There is no need to limit conversations with the child. However. the nurse should speak in a calm. gentle. reassuring voice.Option C: The child needs gentle and calm bathing. Because of the acuteness of the infection. sponge baths would be more appropriate than tub baths.Option D: Although treatments need to be completed as quickly as possible to prevent overstressing the child. any treatments should be performed carefully and at a pace that avoids sudden movements to prevent startling the child and subsequently increasing intracranial pressure.

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6.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

A.

Hemorrhagic skin rash
B.

Edema
C.

Cyanosis
D.

Dyspnea on exertion

Correct Answer
A. Hemorrhagic skin rash

Explanation
DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

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7.

When interviewing the parents of a 2-year-old child. a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?

A.

Bladder infection
B.

Middle ear infection
C.

Fractured clavicle
D.

Septic arthritis

Correct Answer
B. Middle ear infection

Explanation
Organisms that cause bacterial meningitis. such as pneumococci or meningococci. are commonly spread in the body by vascular dissemination from a middle ear infection. The meningitis may also be a direct extension from the paranasal and mastoid sinuses. The causative organism is a pneumococcus. A chronically draining ear is frequently also found.

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8.

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

A.

Head tilt
B.

Vomiting
C.

Polydipsia
D.

Lethargy
E.

Increased appetite
F.

Increased pulse

Correct Answer(s)
A. Head tilt
B. Vomiting
D. Lethargy

Explanation
Head tilt. vomiting. and lethargy are classic signs assessed in a child with a brain tumor. Clinical manifestations are the result of location and size of the tumor.

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9.

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines that which of the following results would verify the diagnosis?

A.

Cloudy CSF. decreased protein. and decreased glucose
B.

Cloudy CSF. elevated protein. and decreased glucose
C.

Clear CSF. elevated protein. and decreased glucose
D.

Clear CSF. decreased pressure. and elevated protein

Correct Answer
B. Cloudy CSF. elevated protein. and decreased glucose

Explanation
A diagnosis of meningitis is made by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis. findings usually include an elevated pressure. turbid or cloudy CSF. elevated leukocytes. elevated protein. and decreased glucose levels.

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10.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection. which of the following would be included in the plan of care?

A.

No precautions are required as long as antibiotics have been started
B.

Maintain enteric precautions
C.

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
D.

Maintain neutropenic precautions

Correct Answer
C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

Explanation
A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

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